This is the 2019/20 edition of State of Care
State of Care is our annual assessment of health care and social care in England.
The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
Ian Trenholm, Chief Executive, and Peter Wyman, Chair, introduce this year's report.
This year's main findings.
- The care that people received in 2019/20 was mostly of good quality
- However, while quality was largely maintained compared with the previous year, there was no improvement overall
- Before the arrival of the coronavirus pandemic, we remained concerned about a number of issues:
- the poorer quality of care that is harder to plan for
- the need for care to be delivered in a more joined-up way
- the continued fragility of adult social care provision
- the struggles of the poorest services to make any improvement
- significant gaps in access to good quality care, especially mental health care
- persistent inequalities in some aspects of care
In our State of Care report in October 2019, we said that more and better community services were needed to improve people’s experiences of care. We pointed to the need for better integrated services to prevent people ending up in crisis situations.
We showed that some places had better care than others and there were parts of the country where people might find it harder to access good care. We said that the challenge for government, Parliament, commissioners, national organisations and providers was to change the way services work together so that the right services are being commissioned to deliver what people need in their local area.
This emphasis on community and working together is not a new theme. In 2017 we reported that more local collaboration and joined-up care was needed, especially with the complexity of demand, such as diabetes, obesity, cancer and long-term conditions, increasing in a health and social care system at full stretch. We said that services had to think beyond their traditional boundaries and reflect the experience of the people they support.
In 2018 we reported how ineffective coordination of services was leading to fragmented care. Funding, commissioning, regulation and performance management all conspired to encourage a focus on the performance of individual organisations, rather than ensuring people got joined-up care based on their individual needs.
Communities matter. For several years, we have been stressing the huge importance of local health and care systems that work closely together, of collaboration among providers and local organisations to put people at the centre of their care.
The importance of this is much more apparent in the light of the coronavirus pandemic that reached this country in the last two months of 2019/20.
This report looks at the quality of care in our health and care system over the past year, including the period before COVID-19 burst into the national consciousness and began to affect everyone’s lives so fundamentally.
- Quality overall before the pandemic
- Care that is harder to plan for was of poorer quality
- Care services needed to do more to join up
- Adult social care remained very fragile
- Some of the poorest quality services were struggling to make any improvement
- There were significant gaps in access to good quality care
- Deprivation of Liberty Safeguards
- Inequalities in care persisted
- As the pandemic gathered pace, health and care staff across all roles and services showed resilience under unprecedented pressures and adapted quickly to work in different ways to keep people safe.
- In hospitals and care homes, staff worked long hours in difficult circumstances to care for people who were very sick with COVID-19 and, despite their efforts to protect people, tragically they saw many of those they cared for die. Some staff also had to deal with the loss of colleagues to COVID.
- A key challenge for providers has been maintaining a safe environment – managing the need to socially distance or isolate people due to COVID-19. Good infection prevention and control practice has been vital.
- The crisis has accelerated innovation that had previously proved difficult to mainstream, such as GP practices moving rapidly to remote consultations. The changes have proved beneficial to, and popular with, many. But many of these innovations exclude people who do not have good digital access, and some have been rushed into place during the pandemic.
- The pandemic has had a major impact on elective care and urgent services such as cancer and cardiac services, and there is huge pent-up demand for care and treatment that has been postponed.
- The pandemic is having a disproportionate effect on some groups of people, and is shining a light on existing inequality in the health and social care system. It is vital that we understand how we can use this knowledge to move towards fairer and more equitable care, where nobody’s needs go unmet.
- It is important that the learning and innovation that has been seen during the pandemic is used to develop health and social care for the future. New approaches to care, developed in response to the pandemic and shown to have potential, must be fully evaluated before they become established practice.
- The success of collaboration between provides to keep people safe was varied, often affected by the maturity of pre-existing relationships within the system.
- Understanding the needs of local populations, including cultural differences, was especially important.
- Sectors did not feel consistently engaged in the coordination of responses to the crisis.
- Health and social care staff worked above and beyond, with a shared drive to look after people well and keep them safe.
- System areas benefitted from the pace of effort to secure a regional level grip across communication, support and joint working approaches in response to confusion from the pace of national guidance.
- The voluntary sector played a critical role in supporting health and social care to keep people safe. System-wide leaders were concerned about capacity to meet the demands of subsequent peaks without this support.
- Where we found well planned governance, clear decision-making arrangements and escalation plans, those system-wide responses were most effective.
- Areas with sector and pathway oversight cells secured increased communication, timely information sharing and collective partnership decisions.
- Where we found multiple or unclear governance arrangements, those areas experienced higher levels of confusion and duplication of effort.
- The engagement of all sectors to system level responses varied. Where there was less engagement, there was a disconnect between communication and information within and across providers.
- Views of sector partners varied as to the effectiveness of joint and supportive working arrangements, particularly between care homes and GP practices.
- Strategies to manage staff and resources across sectors and partnerships were inconsistently navigated, causing varied success of collaboration within systems.
- Initiatives to manage professional skills capacity across providers was managed well in some areas, with demonstrable impact.
- A wide range of measures were introduced to keep staff safe, although implementing them caused challenges.
- Accelerated and shared digital approaches supported providers to work together and keep connected well.
- Advanced IT and technology did not always assist with efficient and timely access to care for people.
- At times the pace of change felt overwhelming for health and social care providers.
The speed and scale of the response required by the COVID-19 pandemic early in 2020 has highlighted the benefits to services, and the people who use them, of creativity and innovation through collaborative working.
In July and August 2020, we rapidly mobilised teams to carry out provider collaboration reviews in 11 different English localities, to find out how providers had worked together in the face of the pandemic. The reviews have brought into focus themes and learning that can be used to inform planning for this autumn and winter with the resurgence of COVID-19.
The reviews focused on care for people aged over 65 – the age group most impacted by COVID-19. The 11 integrated care system (ICS) or sustainability and transformation partnership (STP) areas were:
- Bedfordshire, Luton and Milton Keynes ICS
- Devon STP
- Frimley Health and Care ICS
- Lancashire and South Cumbria ICS
- Lincolnshire STP
- Norfolk and Waveney STP
- North East and North Cumbria ICS
- North West London STP
- One Gloucestershire ICS
- Sussex Health and Care Partnership ICS
- The Black Country and West Birmingham STP.
We had four areas of focus for our reviews and some key questions about the response to COVID-19:
- People at the centre: How did providers collaborate to ensure that people moving through health and care services were seen safely in the right place, at the right time, by the right person?
- System leadership: Was there a shared plan, values and system-wide governance and leadership during the first months of the pandemic in England?
- Workforce capacity and capability: Was there a strategy for ensuring sufficient health and care skills across the health and care interface?
- Digital solutions and technology: What impact have digital solutions and technology had on providers and services?
To get a comprehensive picture, we spoke to a wide variety of organisations locally, including primary care networks, local medical committees, adult social care providers, social services teams, NHS trusts and independent hospitals, urgent care providers, NHS 111, community care providers, integrated care teams, urgent dental services and local Healthwatch.
The individual reviews helped to identify where provider collaboration worked well to the benefit of local people. The reviews have drawn out examples of creativity, innovation and rapid new ways of working, as well as identifying the challenges for provider partnerships and those accessing care. Sharing that learning will help drive system, regional and national learning and improvement.
Taken together, the reviews have brought into focus the themes and learning that can be used to inform planning for the coming winter and any subsequent spikes of COVID-19. But more than that, they are intended to help providers and leaders of local health and care systems plan and work more effectively together as a matter of course.
The reviews bolster recommendations we made in our 2018 report Beyond Barriers, when we called for a reform of planning and commissioning of services, particularly to support older people in their own homes. We said that a new approach was needed for system performance management and joint workforce planning, as well as better oversight of local system performance.
Our ambition is to look at provider collaboration in all ICS and STP areas in England by the end of 2020/21. Our reviews will consider the impact of collaboration across different pathways and population groups. This will include looking at how providers are re-establishing services and pathways in local areas, alongside continued responses to the impact of COVID-19. The next review will focus on how providers are working together to deliver urgent and emergency care services.
- The problems that existed before COVID-19 have not gone away.
- The fact that the impact of COVID has been felt more severely by those who were already likely to have poorer health outcomes makes the need for services to be designed around people’s needs all the more critical.
- There needs to be a new deal for the adult social care workforce that reaches across health and care – one that develops clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation.
- Primary care services need to make sure that people and patients are given the confidence to interact with them early, provide a range of ways for people to access the care they need, and to make it easy for them to do so.
- The increased waiting lists and backlog of urgent and elective care need to be addressed – services need to assess and prioritise patients so that they are treated according to clinical need and that people waiting for long periods for treatment are kept safe.
- We must use the learning from the pandemic to lock in positive changes, and drive a new way of working that is supported at a national, regional and local level by the whole health and care system.
All areas of the health and care system have met the challenges of the pandemic head on, with staff going to great lengths to respond to this unprecedented health emergency. To manage the demand and keep people safe, we have seen services rapidly adapting the way they work.
But alongside the recognition that COVID-19 has fundamentally changed so much, it is important to recognise what has not changed. The problems that existed before COVID have not gone away. People are still more likely to receive poorer care from some types of service, and from some providers, for the same reasons that they would have been more likely to receive poorer care before. We will maintain scrutiny on these services and providers, supporting improvement and taking action to protect people where necessary.
Throughout the pandemic it has been important to have a learning culture and proactively respond to emerging best practice. Looking forward, we need to harness that learning and focus on what needs to be done to keep people safe, and at the same time continue to make sure people have access to high-quality care that meets their individual needs.
Coming together to ensure people continue to get the care they need
Val and Peter are a married couple in their eighties. Peter has motor neurone disease, and Val has been his main carer for the nine years since his diagnosis. In the past three years, as Peter’s condition has worsened, he has been unable to leave their home. Peter is now paralysed from the neck down, and needs a ventilator to help him to breathe.
Val and Peter are supported by carers who visit three times a day, a specialist hospital in London, a local motor neurone disease specialist nurse, their GP and pharmacy, district nurses, and the Motor Neurone Disease Association charity. Val told us that, when pandemic lockdown measures were introduced, she expected that some of this support might change or fall away.
Instead, support has continued for both Val and Peter. The care agency has managed to make sure that the same carers attend to help Peter with personal care, which is important to him as some of this – such as bathing – is very intimate. The only change has been in the PPE that they must now wear. The specialist nurse, who used to visit them monthly, now contacts Val and Peter on the phone to check in and make sure they have everything they need. Their GP has also provided remote appointments, and the pharmacy is continuing to deliver medicine to their home.
Support groups provided by the Motor Neurone Disease Association have moved to Zoom, which Peter can access on a specialised computer and which he operates with an eye-tracking device instead of a mouse and keyboard. This has been an improvement for Peter as, despite technical issues, he has been able to attend for the first time since he stopped leaving the house.
Val works hard to provide Peter with care, and while lockdown has not changed this, the couple are hoping to arrange some respite care for Peter during the week. This would mean Val could leave the house for longer periods to socialise, without worrying about Peter or having to frequently check her phone.
Having the consistent support of health and social care services has lessened the impact of the pandemic on Val and Peter, and the couple are very appreciative of the help they receive.
The commitment and resourcefulness shown by health and care staff during the pandemic has been recognised by the public in a groundswell of appreciation. Our research has shown that people are more likely to engage with their local services: since the start of the pandemic, more than two-thirds of people said they would be more likely to act to improve health and social care services, and 57% said that they would be more willing to support services by actively providing feedback on their care.
We have joined forces with Healthwatch England to launch a joint new campaign Because We All Care to help shape health and social care. The campaign aims to support and encourage more people in England to give feedback on health or social care services that they or a loved one have experienced.
It is important that the learning and innovation that has been seen during the pandemic, both in individual services and in local systems, are used to develop health and social care for the future. This applies to both the short term, in planning for the coming winter, as well as longer-term strategic planning.